An equitable and effective healthcare system, then, one that supports basic American principles by straddling the upper quadrants of the healthcare landscape, is at least imaginable. Achieving such a system requires acknowledging limits to what our healthcare system can provide and then ensuring that those limits are distributed justly. By allowing the American spirit of individualism and innovation to guide our efforts, we can make this new system-even with the open rationing it will require-energizing instead of enervating to our society.

But how can we begin to make it real? Let's first look at the likely outcome if we do nothing.

Wonkonians ascendant

In the battle between Wonkonians and Gekkonians over whether our Quadrant III healthcare system will be controlled by the government or by business-like enterprises, the Wonkonians are on the ascent. Since the 1994 collapse of the Clintons' universal healthcare plan, Gekkonians have had their chance to show what they can do. They have had more than a decade to wield their mega-HMOs in an effort to control costs. But despite the inconveniences and dangers they have foisted on American patients, despite the intensity of their coercive efforts to force covert rationing, and despite the opportunities they have created for greater efficiency by promulgating massive consolidations of healthcare institutions, Gekkonians have proven failures at controlling the accelerating cost of healthcare. What's more, they have discharged their only weapons and they seem bereft of new ideas.  In truth, Gekkonians really had only one idea. They have had many years to try it. It hasn't worked.

Wonkonians, on the other hand, remain energized by their one big idea, the establishment of a fully centralized, government-controlled, top-down system of healthcare. The model they invoke most often is the Canadian healthcare system. Wonkonians, in addition to not being Gekkonians, are further advantaged by being single-minded about their plans for healthcare; they are politically savvy, well organized, and generally favored by the mass media. Their basic message-that their healthcare system will be fair-is attractive, especially in view of what we have today. And they have absolutely no trouble showcasing satisfied Canadian citizens (presumably from among the ninety percent who have not been seriously ill recently) who are happy to offer testimonials confirming Wonkonians' claims about this style of healthcare. Wonkonians have never stopped lobbying and working for their big idea, and it is likely that if the healthcare debate of 1994 were taken up again today, they would enjoy the support of a substantial proportion of the American public. Although I would find such a system extremely undesirable, I will stipulate that with some care it could be made more equitable-and ethically more acceptable-than the system we have now. (But then, it is difficult to imagine a healthcare system that would be more unfair and destructive than the one we have now.)

Politically, however, Wonkonians were damaged so badly by their prior ill-conceived attempt at a government-controlled healthcare system that they seem reluctant to push too hard or too soon this time. The disadvantages of a Canadian-style healthcare system remain all too visible-the long queues, the lack of real medical innovation (except via osmosis from the United States), and the dissatisfaction voiced by increasing numbers of Canadian citizens and doctors. These factors are keeping Wonkonians relatively cautious. But they can see that Gekkonians are failing badly; they can afford to wait.

Biding their time is a wise strategy. A centralized healthcare system that subjects Americans to centrally dictated, population-based, government-controlled decision trees would rub Americans the wrong way. That kind of system relies on a compliant, passive, fatalistic populace resigned to a much lower level of self-determination than Americans have traditionally enjoyed. Today, as in 1994, a majority of Americans would not fit this description.

But several more years of being subjected to Quadrant III healthcare may get us there. This is almost certainly what Wonkonians are relying on. Each day we remain under our present system of inefficiency and inequity, more Americans become completely fed up and resign themselves to the idea of a single-payer, government-controlled healthcare system. It seems to be the least bad of several very bad choices. All Wonkonians have to do is continue advancing the perfidies of our present system and wait. The people will come around.

It is a good strategy, and there is an excellent chance that it will work. Short of riding out our current piecemeal, largely Gekkonian system of covert rationing to the end, that is, until the fiscal time-bomb it is creating actually goes off and wrecks our society, most Americans would find it hard to imagine an alternative to the Wonkonian "solution."

Only one thing can steer us away from the Wonkonian solution - empowering patients to act on their own behalf. Patients with sufficient knowledge and the systems to apply that knowledge will not only wreck covert rationing (which relies on patients being complaisant) but will also make the Wonkonian healthcare solution of centralized governmental control completely unworkable. We will have to discover an alternative to both Gekkonians and Wonkonians; and patient empowerment will reveal to us what that alternative should look like.